James Militzer: What do you think about the challenges of untrained, unlicensed providers, and their role in health care delivery in India? Are they a threat to patients that needs to be discouraged, or is there a way to train, license and utilize them to improve public health?

Zeena Johar: I have a split opinion about that. I agree, untrained providers are definitely a threat to the system, in terms of unethical practices and care which is completely not evidence-based. And we have very weak regulations in our country, so of course we can put regulations in place, and we need to systemize them. I don’t know how we can train [informal providers], and I don’t think that is a possibility.

But we are talking about putting together market-driven models for primary care, and these people have flourishing practices, in a way. Quacks end up seeing 30, 40 patients in one day, and they see that many because local people in some shape or form trust them and like them, and are willing to pay for their services. The people we serve often trust their opinion more than they trust the opinions of formal providers.

One very simple reason is that they have seen that quack for the last 20 years, and maybe for many generations. Whereas formal providers are outsiders coming in, giving them lectures on risk assessment and cardiovascular diseases, their informal provider understands them through and through, and has solutions in the form of injections, which can put them back on their feet in a day’s time. What do they care about the long-term, 20-year implications?

This is more about alternate competition coming in, and competition driving the quacks out, in terms of the quality of care, in terms of standards, integrated care, and people seeing value in the alternate system. I think regulations can control quacks, and in some states they do, by not allowing them. But I think ultimate success will only come when competition primarily rules them out.

Because you know, the person who is paying for the service, at the end of the day, will go to the provider that they’re most comfortable with. Until you have a value proposition in hand that’s much stronger than that of the quack, whatever you do, they will still like going to the quack.

JM: So what should a private enterprise do to compete? If they’re trying to sell safer, evidence-based treatments that don’t bring the immediate results of a quack’s remedies, how do they make the sale?

ZJ: This is a very difficult question to answer, and these are the problems we struggle with on a day-to-day basis. But my hunch is that people will come if we are present in the community long enough and have an integrated care network, and can say, “I am the primary care provider, and this is the secondary care provider that I will guide you to if there is something that I cannot do, to make sure that the same quality of care will be provided, and you will be taken care of. And then, if the secondary care provider can’t give you options, this is the tertiary care that you need to go to.”

That is the advantage that we have: quacks will not be able to provide integrated care. A quack cannot necessarily refer you to a tertiary care hospital, and then make sure that through financing mechanisms, you don’t pay anything. So the villagers will see that the primary care provider is part of a much larger network, and all their problems in health care can be addressed if they enter that facility. And the community begins to trust us – through people saying “There was a heart attack in the community, and through this network the person got cured.” This is how I think the rural markets will begin to believe in systematic care delivery. If the entire system adds up, it will automatically flush out all these practices which are stand-alone, which definitely cannot integrate.

JM: As the current system exists, do patients have to see a primary care physician to be referred to secondary or tertiary care?

ZJ: No, anybody can go anywhere they want, which is why patients end up going to the senior-most physician they know. If you have shortness of breath, you go to the cardiologist’s office.

JM: So patients self-diagnose, then seek out a specialist for the problem that they think they have?

ZJ: Absolutely. Absolutely

JM: Is there a challenge in getting people to think about health care as a step-by-step process, starting with primary care, which can seem like a waste of time for people who think they already know what they have?

ZJ: There definitely is. People say, “OK, I’ve come in with a cough and a cold, why are you spending time talking about my blood pressure?” For them to understand the concept of opportunistic screening, or to appreciate that health is not just treating their immediate symptoms, but to have a fuller perspective – that will take time.

But that’s a shift which will happen for sure, because that’s where the markets will eventually go when you’re talking about integrated care. In our geography, initially, patients didn’t understand why we were putting them through this comprehensive process. But now they have started to enjoy the interaction, because they know that we will spend time in understanding not only the current problem that they came in with, but how they are doing overall.

(Left: Zeena Johar)

JM: If a private enterprise wants to set up primary care clinics in India, would you suggest that they base their business model on the expectation that patients will be paying out of pocket for the foreseeable future? Or should they expect to see the government-subsidized health insurance model extended to primary care in the short or medium term?

ZJ: I would say that creating a business model which will be driven by government subsidy is a big disaster in the making. If you want to create a sustainable business model doing evidence-based care, you should be willing to be patient, and to suffer a little loss, and wait for the market to evolve.

But if you want to create a sustainable business enterprise, it’s not about meeting every health care need. All women need to go to cervical screening, but if they’re not willing to pay for it, you don’t provide that in your setup. But if they are willing to pay for the services that they perceive are more important, as an entrepreneur you need to get started on that. And once you have demonstrated trust and viability, that’s when you bring in harder interventions, like cervical screening, which need behavior change.

JM: What do you see as the main areas of demand in health care, and the most promising needs for a new business to focus on?

ZJ: From my personal experience, the easy sells are the ones which are visible, like acute conditions. They are easy because people see the difference immediately. If you have fever, or body pain, or a dermatological infection, they can be treated very systematically, and in four days either you will be better or you will not be better. These are very systematic, short-term conversations, so building a framework around acute care is easy.

Chronic care is for patients who are suffering and are already spending a lot of money in the current market on their condition. So if you can systematically provide them with a solution in terms of case management and diagnostics, it is also a relatively easy sell.

Diagnostics is a market which is not being tried out at all. As I was saying, a quack can give you a steroid injection, but he cannot necessarily do a blood test. So in a market that has very limited access to a lot of essential diagnostic services, that would be an easy starter. And then you add on other interventions.

Ophthalmology is a very easy starter, because somebody walks into the clinic and cannot see, and you have a systematic process of looking at their vision, then you give them either a pair of reading or distant vision glasses, and boom! That person can see better. Everything that has a very clear value proposition is easy to build into your basic business model.

JM: But what if the private sector is focusing only on visible things, or things that they can improve quickly and noticeably for patients, rather than on things that are not as noticeable but are equally or more harmful? What’s the best way for the health system in total to address those issues?

ZJ: The way the environment is developing, the government wants to provide universal health care, so in various shapes and forms, I’m sure there will be opportunities available through the government network to facilitate all of these services to our population.

And even within the private sector, I refuse to believe that there’s a market only for the visible health needs. Of course, initially, absolutely – you need to run with the low-hanging fruit, and only then aim for the tougher solutions. But if you are in the geography, and people trust you for services A, B and C, and then you go launch services D, E and F, I’m sure that because you have the reputation within the community, they will be willing to hear you out even for other interventions that you are offering.

JM: So in the long term, do you see the public and private sectors gravitating toward separate health needs? Or do you think that both will try to offer a full range of products to patients, and patients will decide which of the two sectors they want to go to for their health care?

ZJ: I would expect to see the kind of evolution that we have seen in tertiary and secondary health care markets. Once the private sector is well-evolved, the government and private sector will end up working very closely with each other – in terms of having common infrastructure, or having subsidies, or having some other monitoring mechanism. I think this will happen especially in primary care, because there is a challenge of accessibility, wherein you have to be present in many more locations than other hospital providers.

We’ve seen that in other spaces too. As they evolve, the two sectors begin to work with each other. And one either pays or regulates and controls for the outcome, and the other, which offers better efficiency, goes out and delivers the care. Most of the time, this ends up being the private care provider. But right now there is no model for the two of them to come together and work as partners.